OMEGA PSI PHI FRATERNITY, INC. INTERNATIONAL …

FORM 9A

REPLACES 9A, 9B AND 12;PREVIOUS EDITIONSARE OBSOLETEREVISED 03/2006

Founders: Frank Coleman, Oscar J. Cooper, Ernest E. Just. Edgar A. Love (Deceased)OMEGA PSI PHI FRATERNITY, INC.

INTERNATIONAL HEADQUARTERS3951 Snapfinger Parkway, Decatur, Georgia 30035

APPLICATION FOR MEMBERSHIP

1. Read all instructions and questions before you start2. Please SEPARATE AND TYPE answers to all questions. Re-staple when completed.3. After you have completed this application, check to make sure you have answered all questions.4. Be sure to sign your completed application in BOTH sections of Part IV.

FOR OFFICE USE ONLY DO NOT WRITE BELOW THIS LINE_______________________________________________________________________________________

_____________ Approved or Disapproved ______________

Applicant’s Full Name ________________________________________________________________________________________________First Middle Last Suffix

Control/Membership No. _____________________________ Date of Birth __________________________ DOD _________________

Street Address _______________________________________________________________________________________________________City ______________________________________________ State _________________________________ Zip Code ________________

Telephone _________________________________________ Chapter _______________________________ DOI ___________________

Friendship is Essential to the Soul Ωφεληµα Ψυχι Φιλια~ APPLICATION FOR ADMISSION TO MEMBERSHIP

OMEGA PSI PHI FRATERNITY, INC.

PLEASE TYPE

PART I. PERSONAL INFORMATION:

Applicant’s Full Name ________________________________________________________________________________________________________________(First) (Middle) (Last) (Suffix)

Permanent Home Address _____________________________________________________________________________________________________________

City ________________________________________________________ State _________________________ Zip ______________________________

Residence Telephone __________________________________________ School or Office Telephone ______________________________________

Present Address (if different from above) _______________________________________________________________________________________________________________

City __________________________________________________________ State ______________________________ Zip ________________________________

Date of Birth ____________________________________ Marital Status ______________________________ Number of Children ____________________

If yes, list dates you AppliedHave you ever applied to: A. Omega Psi Phi? Yes No

B. Other Fraternity? Yes No

Are you currently employed? _________________ If yes, Occupation; (use Codes on last page) __________________________________________ Undergraduate students enter 00

□ Part –Time □ Full –Time Place of Employment: _____________ ____________________________________________________________________ _______________-

Father’s Full Name ___________________________________________________________ Is he living? ______________________________________

Father’s Occupation (use Code # on last page) __________________________________________________________________________

Mother’s Full Name __________________________________________________________________ Is she living? ________________________________

Mother’s Occupation (use Code # on last page) ___________________________________________________________________________________________

Number of Brothers ___________________ Ages ____________________ Number of sisters ___________________ Ages ___________________

Number of Dependents (Spouse/Children) _______________________________ Ages ___________________________________________________

Number of brothers/sisters in college __________________________________

Name other members of your family who belong to a fraternity or sorority. Specify their relationship to you and list organizations to which they belong.

Name Relationship Organization

___________________________________________________________________________________________________________________________________________________________________________________________________

Ωφεληµα Ψυχι ΦιλιαFriendship is Essential to the Soul

Page 2 of 23PART II. ACADEMIC INFORMATION

Academic classification: □FR □SO □JR □SR □Post-Baccalaureate □Grad. Student □ OtherSpecify Other ______ _____ _______________________

Grade point average in undergraduate college? _________________________________________________________ (on a 4.0 system)

UNDERGRADUATE COLLEGES ATTENDED(List in chronological order all undergraduate colleges you have attended or are currently attending. Include summer sessions.)

Institution/Location Dates of Attendance Major (See codes last page) Degree and Date Conferred or expected (Month and Year)

_______________________________ _____________________ ________________________ _____________________________

_______________________________ _____________________ ________________________ _____________________________

_______________________________ _____________________ ________________________ _____________________________

_______________________________ _____________________ ________________________ _____________________________

_______________________________ _____________________ ________________________ _____________________________

GRADUATE/PROFESSIONAL SCHOOLS ATTENDED(List in chronological order all undergraduate colleges you have attended or are currently attending. Include summer sessions.

Institution/Location Dates of Attendance Major (See codes last page) Degree and Date Conferred or expected (Month and Year)

_______________________________ _____________________ ________________________ _____________________________

_______________________________ _____________________ ________________________ _____________________________

_______________________________ _____________________ ________________________ _____________________________

_______________________________ _____________________ ________________________ _____________________________

_______________________________ _____________________ ________________________ _____________________________

Note: Official transcript(s) bearing the university seal must be sent directly to the District Representative. Undergraduates must also have acertification form sent attesting to enrollment as a full-time student.


Page 3 of 23PART III. BIOGRAPHICAL INFORMATION

1. How did you first learn about Omega Psi Phi Fraternity? Be as specific as you can be.

2. Describe jobs or positions of responsibility that you have held. If you have had experience in community service, what contributions have youmade? Include dates and leadership positions held.

3. Give names and complete addresses of 3 individuals who have written reference letters for you.

___________________________________________________________________________________________________________________________________________________________________________

4. Extra-curricular activities: Describe and comment on hobbies, recreational activities and other uses of your time. Name significant positionsyou held in college.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Page 4 of 23

5. In 200-250 words, state your purpose for applying at this time. Indicate how you perceived the fraternity can assist you in achieving yourcareer goals. In the process, please provide details on your background and motivations. Your response may not exceed and must be typed inthe space provided below. (You may adjust the font to an appropriate size.)


Page 5 of 23

6. Write a 500 word essay about a famous Omega Man. Your response may not exceed and must be typed in the space provided below. (You mayadjust the font to an appropriate size.)


Page 6 of 23

FORM 9AAttachment 1Revised 07/05

PART IV A. CERTIFICATION

Name (Print) _________________________________________________________________________________________________________

Address ____________________________________________________________________________________________________________

I understand that withholding information requested on this form or knowingly giving false information may make me ineligible for admission to Omega Psi Phi Fraternity, Inc. or subjectto dismissal, if determined after I become a member. I certify that the statements I have made on this application are correct and complete to the best of my knowledge, information andbelief.

AS A CONDITION OF MY PARTICIPATION TN THE OMEGA PSI PHI FRATERNITY, INC.’S MEMBERSHIP INTAKE, I DO HEREBY ENTER IN THEFOLLOWING STIPULATIONS. COVENANTS AND AGREEMENTS:

I certify that I am aware of the fact that Omega Psi Phi Fraternity, Inc. expressly prohibits and vehemently opposes the use of physical or mental harassment/hazing in any of its activities.I understand that hazing includes but is not limited to physical violence such as paddling, slapping. pushing of my body by of any object, device or hand; strenuous exercise, forcedinducement or the causing of me to consume any food, liquid or other substance, pouring sprinkling or covering of my body with airy substance; threatening or causing me to be placed infear of receiving any physical injury such as the activities listed above and generally any act or acts which would tend to cause any person any humiliation, embarrassment or physicalharm. I agree that I shall never permit any acts of hazing, whether they be physical or mental, to be used against me before, during or after The Membership Intake Program. I further agreeto report any acts of hazing or attempted hazing promptly to the Regional Intake Team in writing with a copy to the District Representative. I understand that no punitive action will betaken against me for rendering said report. Further, I understand that failure to render said report shall serve as sufficient cause for my dismissal from the intake program or from theFraternity if admitted. Additionally, I have been informed that I am entitled to receive a listing of the fees associated with admission to membership in the Fraternity and a copy of theroster which lists the financial members of the Chapter. I understand that only the members of the Regional members of the Regional Intake Team are permitted to he involved with meand my activities as a prospective for membership.

I understand that the Omega Psi Phi Fraternity, Inc is a non-profit corporation, having Its domicile and principal place of business in Washington. District of Columbia. I hereby stipulateand agree that any and all lawsuits other than claims that I may have arising out of my participation in the Omega Psi Phi Fraternity, Inc. Membership Intake Program shall be governed bythe laws of the District of Columbia and that such lawsuits and claims shall be brought, filed sued upon solely within the jurisdiction of the courts of the District of Columbia.

I certify that I have read this document thoroughly and understand same; that I agree to and do bind myself to all of the terms and conditions contained herein. Accordingly. I do herebyrelease the Omega Psi Phi Fraternity, Inc. and do hold same harmless, as well as its insurers, employees, agents, successors and assigns from any and all liabilities for damages incurred byme as a result of my participation in its Membership Intake Program. I further bind my legal representatives, heirs, successors and assigns to the terms and conditions of this agreement.

I agree that, should any part of this agreement be found to be illegal for any reason, the illegal part or parts shall he severed hencefrom and the remaining agreements and stipulations shallbe given full force and effort as if those severed did not exist.

I certify that I am at least eighteen years of age, or that lam the parent or legal guardian of the applicant herein and do exercise this document on his behalf. Further, I certify that I enterinto these stipulations and agreements knowingly, freely and without duress or coercion of any kind.

Witness my hand and seal this _________ day of _____________________, 20____, city/state ________________________________________________

__________________________________________________________ ________________________________________________________Applicant Name (Print) Notary Public’ Signature

__________________________________________________________ ________________________________________________________Signature: Applicant/Parent/Legal Guardian Commission expires (Date)

_______________________________________________________ Seal


Page 7 of 23

Form 9A-20 OMEGA PSI Pill FRATERNITY, INC.

ACKNOWLEDGEMENT AND INDEMNIFICATION AGREEMENT

Name of Applicant or Member (Print) _____________________________________________________________________________________________________________________________________

Social Security Number (Applicant) _______________________________________________________________________________________________________________________________________

Street Address _____________________________________________________________________________________________________________________

City/State/Zip Code __________________________________________________________________________________________________________________

Chapter Name _______________________________________ CHAPTER LOCATION ______________________________________________________

I certify that I am aware of the fact that Omega Psi Phi Fraternity, Inc. expressly prohibits and vehemently opposes the use of physical or mental harassment/hazingin any of its activities. I understand that hazing includes, but is not limited to, physical violence such as paddling, slapping, pushing of another’s body, by use of anyobject, device or hand; strenuous exercises; forced inducement or the causing of another to consume any food, liquid or other substance; pouring, sprinkling orcovering of another’s body with any substance; threatening or causing another to be placed in fear of receiving any physical injury such as the activities listedabove and generally, any act or acts which would cause any person any humiliation, embarrassment or physical harm.

I agree that I shall report any acts of hazing or attempted hazing promptly to the Membership Selection Team in writing with a copy to the District Representative,or directly to the District Representatives. I understand that failure to render said report shall serve as sufficient cause for my dismissal from the Fraternity.

I understand that the Omega Psi Phi Fraternity, Inc is a non-profit corporation, incorporated in the District of Columbia, and having its domicile and principal placeof business in Decatur, Georgia.

I understand that the only agents of the Fraternity are the Supreme Council and/or the Brand Conclave, who may from time to time, employ persons or firms to acton behalf of the Fraternity. I understand that, as member or potential member of Omega Psi Phi Fraternity, Inc., I am not an agent of the organization. Further, Iunderstand that I have no authority whatsoever to enter into any agreements, whether oral or written that would obligate Omega Psi Phi Fraternity, Inc. in any way.

I certify that I have read this document thoroughly and understand same; that I agree to and do bind myself to all of the terms and conditions contained herein.Accordingly, I do hereby release and indemnify the Omega Psi Phi Fraternity, Inc. against any claim, loss, damage, or expense caused by me for actions whichsubject the Fraternity’s assets to judgments for losses, damages or expenses awarded by a court or agreed upon in settlement negotiations. I further bind my legalrepresentatives, heirs, successors and assigns to the terms and conditions of this agreement.

I certify that I am at least twenty-one (21) years of age or that I am the parent or legal guardian of the undersigned and do exercise this document on his behalf.Further, I certify that I enter into these stipulations and agreements knowingly, freely and without duress or coercion of any kind. I further certify that my date ofbirth is _______________________________________________________________________________________________________________________

Witness my hand this __________________________ day of , 20____, city/state ___________________________________

_______________________________________________ ______________________________________________________Signature: Applicant or Member Signature: Notary Public

________________________________________________ _______________________________________________________ Signature: Parent/Legal Guardian if member Commission expires (Date)Is under 21 years of age

Parent’s Address __________________________________ Seal

_________________________________________________


Page 8 of 23

The principal purpose for requesting the information on this form is to conduct background checks on individuals petitioning for membership in Omega Psi Phi Fraternity, Inc.Furnishing all information requested on this form is mandatory. Failure to provide such information shall result in a determination that the applicant is ineligible for membership or not appropriate for consideration.I hereby aggress to permanently waive and forego any rights or causes of action I may have against Omega Psi Phi, and its agents, officers or assigns as a result of the use, release or dissemination of the collected information and shall indemnify and hold harmless the Fraternity, its chapters, Districts, officers, assigns, or successors in interest from any and all liability that may result from the use, release or dissemination of the collected information.

FORM 9AAttachment 2-1Revised 03/06

OMEGA PSI PHI FRATERNITY, INC.AUTHORIZATION TO RELEASE INFORMATION FORM

Printed Name: ________________________________________________________________________________________________________Last First Middle

Date of Birth ____________________________ Social Security # _______________________________________Home Phone Number ___________________________ Business Phone # _______________________________Other Names You Have Used ______________________________________________________________________

Current Address:

_______________________________________________________________________________________________Street Number and Name City State Zip How Long?

Have you been background checked by Omega Psi Phi Fraternity previously? □YES □NO

If yes, please note date (approximate): ____________________________________________________________________________________

HAVE YOU BEEN COVICTED OF FELONY, MISDEMEANOR CONVICTION, OR OTHER CRIME, BY ANY COURT YOU MAY OMIT? MINOR

TRAFFIC VIOLATIONS FOR WHICH THE FINE IMPOSED WAS $400.00 OR LESS.□YES □NO

If yes, please indicate date, location and explanation

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HAVE YOU BEEN CONVICTED OF A CRIME UNDER ANOTHER NAME? □YES □NO

IF YES, STATE NAME: ______________________________________________________________________________________________________________

Complete driver’s license information.DRIVER’S LICENSE INFORMATION: _________________________________________________________________________________________________

License number Expiration Date State of Issue Notice

I hereby certify that all statements on this application are true and correct to the best of my knowledge and belief. I understand that Omega Psi PhiFraternity, Inc. solicits this information so as to be informed of my previous record and character. I understand that consideration of mymembership application depends upon successful completion of a background investigation. If granted membership, I understand that anyfalsification, misrepresentation or omission of facts of this record may be considered cause for expulsion.

Applicant Signature ___________________________________________ Date ___________________________________

FORM 9AAttachment 2-2Revised 03/06

OMEGA PSI PHI FRATERNITY, INC.FURTHER AUTHORIZATION FOR BACKGROUND CHECK

I understand that in evaluating my application for potential membership and thereafter to evaluate my continuedsuitability or fitness for membership, OMEGA PSI PHI FRATERNITY, INC. may from time to time procure or have prepared anemployment, education, criminal history, motor vehicle, military and/or investigative report about me. I consent to and herebyauthorize OMEGA PSI PHI FRATERNITY, INC. to obtain these reports, and by copy of this authorization, I have been notifiedthat the above stated reports may be requested.

I also authorize OMEGA PSI PHI FRATERNITY, INC. to procure records or other information about my background,character, general reputation, driving record, military service, and/or employment performance in connection with my applicationfor membership and from time to time thereafter in connection with my membership. I authorize all persons, schools, employers,companies, corporations, law enforcement agencies and other government agencies to release documents or other information toOMEGA PSI PHI FRATERNITY, INC. and to any company hired by it. This authorization includes matters of opinion relating tocharacter, ability, reputation and past performance.

If I am offered membership prior to the completion of any of the reports, I realize that my continued participationis contingent upon favorable results of such reports. If unfavorable information is developed, I realize my membershipparticipation is subject to termination.

Name _________________________________________________________________________________________________________________________________________________________________________________________________________

DOB____________________________________________________________________SSN:________________________________________

Current Address _____________________________________________________________________________________________________________________

Driver’s License No.: State :_____________________________________________________________

Signature ___________________________________________________________________________________________________________________________

If you have a previous address or address within the last tive years, please list below:

Previous address or addresses within the last five years:

1.

Street: _____________________________________________________________________________________________________________________________

City, State, Zip: ____________________________________________________________________________________________________________________________________________________________________________________________

2.

Street: ____________________________________________________________________________________________________________________________

City, State, Zip: _____________________________________________________________________________________________________________________


Page 10 of23FORM 9A

Attachment 2-3Revised 03/06

OMEGA PSI PHI FRATERNITY, INC.FURTHER AUTHORIZATION FOR BACKGROUND CHECK (CONT’D)

3.

Street: _____________________________________________________________________________________________________________________________

City. State. Zip: _____________________________________________________________________________________________________________________

4.

Street: _____________________________________________________________________________________________________________________________

City, State, Zip: _____________________________________________________________________________________________________________________

5.

Street: ____________________________________________________________________________________________________________________________

City, State, Zip: _____________________________________________________________________________________________

If you are under the age of 2l, your parent/guardian must sign this form.

_______________________________________ _________________________________________(Candidate’s Signature) Date:

_______________________________________ ________________________________________(Print Witness or Notary’s Name) (Witness or Notary’s Signature)

_______________________________________ ________________________________________(Print Parent/Guardian Name) (Parent/Guardian Signature)

Ωφεληµα Ψυχι Φιλια

Friendship is Essential to the SoulPage 11 of 23

FORM 9AAttachment 2Revised 07/05

AUTHORITY FOR RELEASE OF INFOMRMATION - PART II

Name Social Security # FOR OFFICE USE ONLY

YOUR MILITARY RECORDHave you ever received other than an honorable discharge from the military? If yes please provide: YES NO

Date of Discharge (Month and Year) Type of Discharge:Have you ever been subject to court-martial or other disciplinary proceedings under the Uniform Code of Military Justice? If “Yes,”list any disciplinary proceeding in the last 15 years and all court-martials.

YES NO

Date (Month/Year_ Charge or Specification Place (City and county/country if Outside the U.S.

YOUR EMPLOYMENT RECORDHas any of the following happened to you in the last 15 years? If “Yes” begin with the most recent occurrence and go backwards,providing date fired, quit, or left, and other information requested.

YES NO

Use the following codes to explain the reason your employment ended:1 – Fired from Job 3 – Left a job by agreement following allegations of misconduct 5 – Left a job for other reasons under unfavorable 2 – Quit a job after being told you’d be fired 4 – Left a job by mutual agreement following allegations of circumstances unsatisfactory performanceDate (Month/Year) Code Employer’s Name & Address State Zip Code

YOUR POLICE RECORDIf you answer “Yes” to a, b, c, d or e below, explain your answer(s) in the space provided. Do not include anything that happened before your 16th birthdaya. Have you ever been arrested, charged, or convicted of a felony offense? YES NO

b. Have you ever been arrested, charged, or convicted of a firearms or explosives charge? YES NOc. Are there currently any charges pending against you for any criminal offense? YES NOd. Have you ever been arrested, charged, or convicted of a felony offense related to alcohol or drugs? YES NO

a. Have you ever been arrested, charged, or convicted of any type of offense? Leave out traffic fines of less than $100. YES NO

Date (Month/Year) Offense Action Taken Law Enforcement Authority or Court (City and County/Countryif outside the U.S.)

State Zip

YOUR INVOLVEMENT WITH ALCOHOL AND DANGEROUS DRUGS INCLUDING MARIJUANA AND COCAINEThis item concerns the use of alcoholic beverages, and the supplying or using, without a prescription, of marijuana, cocaine, hashishnarcotics (opium, morphine, codeine, heroin, etc.), stimulants (cocaine, amphetamines, etc.), depressants (barbiturates, methaqualone,tranquilizers, etc.) hallucinogenics (LSD, PCP, or other dangerous or illegal drugs?

YES NO

a. Do you now use or within the last 5 years have you used alcoholic beverages habitually to excess?

b. Do you now use or within the last 5 years have you used or supplied, marijuana, cocaine, narcotics, hallucinogenics or otherdangerous or illegal drugs?c. If you answered “Yes” to questions a or b above, provide information below relating to the types of substance(s) used, the periods of frequency of use fordangerous or illegal drugs?From (Month/Year) To (Month/Year) Type of Substance Explanation (in your comments be sure to give the frequency of your use

during each period you listed, including the period of most recent use)

CODE SHEET

COLLEGE MAJOR CODESOtt No Maior Undecided 22 Cts’tl Enginecrisg 43 History’ 64. Natural Sciences 83 Pre.nentistOSI Accounting 23 Classics 44 Health Education 65. Neuroscience 04 Psychobiology02 Admtn,straos,n Supervision 24 (‘omntur,,eatians 45 I ii,mc Econo,nics Sb. Nursing 85 Psychi,Iogv(IS Aerepace Engineering 25 Coinpoter Science, Data Processing 46 Horinrs Prttpeorn 67 Notrttion 66 thuhltc Health04 Agneulttu’e Agtonoiny 26 Correertons/Cnminal Justice 47 Hospital Administration 56. Occupational Therapy 67 Radiology]03 Attatone 27 Dentistry 45 Hotel/Motel Manageinoni 69. Oceanography 110 Recreation06 Art(rcopologv 20 nesign 48 iinrna~itiies 70 llpuooetrv 69 Religioiilfheolegy(17 Architectute 29 Dnaano 50 interdisciplinary Stndies 71. Osteopathy 90 Science-GeneralOS Art 30 Ecoooneics/F,nancr SI Journahsm 72 Pathology SI Sociai Work00 Autrononty 3! F.dncatiott’Elernotitarv Sc~cc~ttdory 52 toss’ 73 Percent, el 92 SociolsigIll Biecheiniutri 32 Education . Higher 33 liberal Arts 74 Pliartnaeologo 93 Speech,Ao,hii logyII Hsilogy 33 Engitreering (Not Cic,11 94 library Science 73. Phornacs 94 Statistics12 i4io,nrdcul Ergireci ing $4 English 55 Lingnistics/l.tteratnre 75, T’Iiiiosophy 95 Theatre Arts13 Bioosedteal Science $5 Envitotoocotal 5ttidicn Sb Marketing 77, Physical Therapy 96 Urban Stadies14 Biophysics 35 Film 57 Mathematics 75 Physics 97 Veterinary Medmemne(5 Black Smodtes’Ethnic Siudie,s 37 Food and Nuti tttonlflietetmcs 58 Medicoic 79. Physiology 90 ZoologyIt Botany 30 Foeeigmt Langaage(sI 50 Medical i’echnokigy 0(1 Pirltticel Sciet,ce17 Broadcasting 39 Genetics 6)) Meteorology Oh Pre-MndicinrIS Business Conmierce 40 tieogeaplmy SI Microbiology br BactcrtologylI 9 Business Administratioit 41 Geology 62 Military Scicitcc21) chemistry 42 Guidance Cooncuhug 53 Motic21 kinorna

OCCUPATIONAL CODES00 Full Ttme-Untlcrgraduatc 5ttideitt 21 (‘timpater Fersonttch 42 Hnn,emaher/Fionsewite 64 Paintei ‘PaperhaagorPlsstorer 00 Sales Persoim. Broker(II AecnntttlBiniklseeprn 22 Cock ‘BaLe, 43 Hoosekeepen/Domeutic Wt,ekcr 65 Pharmacist SI Secretary-St ettographer02 Adjuster/Appraiser 23 (‘onnseli,i/l’ersantrel Worker 44 inspector 66 Photographon/Phtilographie Industry 82 Service Teohiticiat,03 Admninisteatttr 24 Csstodta,s,50nitation Worker 45 ironworker 67 Physician 63 Scientist (Natural Physical)04 Agriculture Industry Worker 2$ t.teniiut 46 Jeweler Jewelry Industry 65 PluniberiPipe litre, 64 Scentint ISoetal IPolilicol)(15 AircrafilAtnlinelMtsstlc.’ 26 Dcsigmmcr 47 JudgeiMagistrate 69 Podiatrist 83 Ss,etal Vi’orkci Spacecraft lndustrs’ 27 Dietitian 48 l.aboeutto3t Wm,rkor 70 P,irlal Service Employee 06 Speech Paihm,lmmgisl and Audiologist(lb l.’Iothing Industry NI Drivrr I I’raek/i9ns.Cahl 49 Laborer 71 Prinriog/l’uhlishing Im,dosrrv Pen,o,i,rrl 57 Sarsry,ir07 Arishitect 28 EeonontintfFtnancter 50 Laundry ond Dry Cleaning 72 Psychologist OS Toilor.’Seanistress08 ,Attendantikmde/’sssistaot 30 Lnginccr industry/Personnel 73 Publmc Relations Personnel 89 Tcacltcr ‘Edocator.(19 Attorney SI Electrician SI i,aw Enforcement 0 (Seer 74 Radmo’Tclevmsioit Niottor, Pictunc industry Profc’nstir/insteucttirII) Aototnabtle Sales art) Service 32 F’rtertaoter/Artist,Masiciait 52 Librarian 75 Receptionist 911 ‘IechnicianTechnologistII Barber ~13 Fstertniitator 53 Lacksittith 76 Recreatinit/Letsoce Winker ill ‘rhnra

1tist

12 Bat’tender 34 Ftrefmgbtter 54 Moclitumet 77 Reps irnton 92 b,ndet writer13 BricklayeelStonetnason.’Cetucnt 35 Florisi,’Florol Worker 55 Manager 76 Rescrvationificket/Passengee.TraVeI Agent 93 Urban P loaner Mason 36 Fimod Service Wt,rhcr Sb Mathcmsmtician/Stutislicion 75 Retired 94 Upholsteret14 Busitmessrnoa Entrcprcmtonr 37 Faneral DircctorMortteiott 57 Mechaitic 95 VoterinariaisIS Butcher/Meat Cttitrri Meat Emhal,ner 38 Meier 96 95 otter Waitress ‘ocher 38 Glazier 39 Militoi’s’ Pzro,,nnel 9/ Wrldet ‘Sheet Metal Worhee16 Bayer/Parchantng Agent 39 Goscmnient Employee 611 Minister Clergyition 98 WriicriAnthnr/RepnnteelJanrnalist17 Carpenter 40 Health Care Wsirkcr 1,1 Nunse 9’) Other.Not L,sied AboveIS Ca.shiori’eilcr 41 i ltstsiriorr 62 Operant,19 (.‘hirirpracitrr 1,3 1 )ptttmeirist20 (‘bork/L’laoeal Wo,ker

Omega Psi Phi Fraternity, Inc.3951 Snapfinger ParkwayDecatur, Georgia 30035


Page 13 of 23

FORM 9AAttachment IFRevised 03/06

OMEGA PSI PHI FRATERNITY, INC.

Member Code of Conduct&

Disciplinary Policy

I certify that I have read this document thoroughly and understand same, that I agree and dobind myself to all of the terms and conditions therein.

Name of Applicant or Member ___________________________________________________________________________________________

Social Security Number _________________________________________________________________ DOB _________________________

Street Address ________________________________________________________________________________________________________

City ____________________________________________ State _____________________________ Zip Code __________________________

Signature ___________________________________________________________________________________________________________________________________ Date _____________________________

Chapter Name ___________________________________________________________________ District ______________________________

I certify that I am at least twenty-one (21) years of age or that I am the parent or legalguardian of the undersigned and do exercise this document on his behalf. Further, I certifythat I enter into these stipulations and agreements knowingly, freely and without duress orcoercion of any kind and I too have read Omega Psi Phi Fraternity, Inc. Member Code ofConduct & Disciplinary Policy.

___________________________________________________________________________Signature Parent/Legal Guardian if member is under 21 years of age.


Page 14 of 23FORM 9A

Attachment 1GRevised 03/06

Omega Psi Phi Fraternity, Inc. ________District

RELEASE AND WAIVER

I hereby grant to Omega Psi Phi Fraternity, Inc. an exclusive right to use the described photographsor videotaped likeness of me in whatever manner it deems appropriate, whether for identification orother purposes while I am participating in an intake process of Omega Psi Phi Fraternity, Inc. and atany time subsequent thereto. I acknowledge that the pictures may be duplicated and distributed byOmega Psi Phi Fraternity, Inc. in any and all manner and media throughout the world in perpetuity.

I warrant and represent that I will indemnify and hold Omega Psi Phi Fraternity, Inc., its officers,agents and assigns harmless from and against any and all claims, damages, liabilities, cost andexpenses arising out of a breach of the foregoing warranty.

Dated this _________________ day of ______________________________, _____________________________

Name: _______________________________

Signature: __________________________________(Attach photos here)

Driver’s Lic. No._____________________________

Address:____________________________________

____________________________________________

This form should be sent to the International Headquarters as a part of the candidate’s application with two passportsized pictures attached



OMEGA PSI PHI FRATERNITY, INC.RECOMMENDATION FOR MEMBERSHIP

TO THE APPLICANT: Complete this portion of the form. Then give the form to one of the individuals who will write a recommendation for you.Provide a stamped self-addressed envelope to that individual. The Chairman of the Regional Membership Intake Team will provide the address to which therecommendation is to be sent when completed.

________________________________________________ _______________________________________NAME OF APPLICANT SOCIAL SECURITY NUMBER

TO THE RECOMMENDER: Please answer the following questions concerning the above named applicant.

How long have you known the applicant? (years/months)

Under what circumstances have you known the applicant?

Give specific examples of occasions where the applicant displayed leadership ability. Provide some detail.

Based on your personal knowledge and involvement with the applicant, provide specific examples of his service to the community/and orUniversity.

Provide any other information that you feel will provide additional insight into the following aspects of the applicant’s character:integrity, maturity and responsibility.

(continue on back of page, if necessary)

____________________________________________________________________________________________________________

Recommender’s Name (TYPE OR PRINT) Title/Position

Signature ______________________________________________________ Date _______________________________________________________

Address ____________________________________________________________________________________________________________________________Tel.# ( ) _________________________________________________Control/Membership#: _____________________________________________________ Exp Date: _______________________________



OMEGA PSI PHI FRATERNITY, INC.RECOMMENDATION FOR MEMBERSHIP

TO THE APPLICANT: Complete this portion of the form. Then give the form to one of the individuals who will write a recommendation formyou. Provide a stamped self-addressed envelope to that individual. The Chairman of the Regional Membership Intake Team will provide theaddress to which the recommendation is to be sent when completed.

________________________________________________________________ _____________________________________NAME OF APPLICANT SOCIAL SECURITY NUMBER








____________________________________________________________________________________________________________


Signature ______________________________________________________ Date _______________________________________________________



Page 17 of 23OMEGA PSI PHI FRATERNITY, INC.

RECOMMENDATION FOR MEMBERSHIP

TO THE APPLICANT: Complete this portion of the form. Then give the form to one of the individuals who will write a recommendation foryou. Provide a stamped self addressed envelope to that individual. The Chairman of the Regional Membership Intake Team will provide theaddress to which the recommendation is to be sent when completed.

__________________________________________________________ _____________________________________NAME OF APPLICANT SOCIAL SECURITY NUMBER








____________________________________________________________________________________________________________


Signature ______________________________________________________ Date _______________________________________________________



Page 18 of 23

FORM IAOMEGA PSI PHI FRATERNITY, INC.

MEMBERSHIP SELECTION PROCESSPOLYGRAPH WAIVER

Name of Applicant or Member (Print) _______________________________________________________________

Social Security Number _________________________________________________________________________

Street Address ___________________________________________________________________________________

City/State/Zip Code ______________________________________________________________________________

Chapter Name _____________________________________________ District _______________________

I, __________________________________________ certify that I am at least 21 years of age or that I am the parentor legal guardian of the applicant herein and do execute this document on his behalf. I certify that I enter into thiswaiver knowingly, freely, and without duress or coercion of any kind.

I certify that I have thoroughly read and understand the Fraternity’s policy on Hazing. I am aware of the fact thatOmega Psi Phi Fraternity Inc. expressly prohibits and vehemently opposes the use of physical or mentalharassment/hazing in any of its activities.

I hereby agree, for purposes of investigating acts of harassment/hazing, to submit to a lie detector test administered atthe request of the District Representative. I understand that the cost of this examination is to be borne by the Fraternitywhen so requested.

I further agree that as a condition of my participation in the Omega Psi Phi Fraternity, Inc.’s Membership SelectionProcess as a member or prospective candidate, I do hereby enter into this waiver and stipulation.WITNESS my hand and seal this ______________ day of ___________, 20____

(City/State) ____________________________________________________________________________

_______________________________________________________________________________________________Prospective Candidate’s or Member’s signature

__________________________________________________________________________Parent or Legal Guardian if prospective candidate under 21 years old.

___________________________________ ________________________________

MEDICAL EXAMINATION

Date of examination _______________________________________________________ Applicant’s Date of Birth _______________________

Height ______________________ Weight ______________________ Blood Pressure _________________________________________

NORMAL ABNORMAL COMMENTS

Eyes ______________________ ______________________ ______________________________________________________

Ears ______________________ ______________________ ______________________________________________________Nose, Throat ______________________ ______________________ ______________________________________________________Heart, Lungs ______________________ ______________________ ______________________________________________________Abdomen ______________________ ______________________ ______________________________________________________Extremities ______________________ ______________________ ______________________________________________________Neurological ______________________ ______________________ ______________________________________________________

Allergies to Medicine: _______________ YES ________________ NO If yes, please list: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Restrictions: ___________________________________________________________________________________________________________________

Physician’s Name (print) ___________________________________________________________________________________________________Address: ___________________________________________________________________________________________City/State/Zip: ______________________________________________________________________________________Phone: ____________________________________________________________________________________________

Physician’s Signature ___________________________________________________________________________________________________

Notary Commission Expires (Date)


Page 19 of 23FORM 89

OMEGA PSI PHI FRATERNITY, INCMedical Consent Forms and Releases

Name of Applicant: _____________________________________________________________________________________________________________________________________Last First Middle Initial

Home Address: ________________________________________________________________________________________________________________________________________

City: _____________________________________________________________ State: __________________________________________ Zip Code: _________________

Sponsoring Chapter/Address: ____________________________________________________________________________________________________________________________

Responsible Party in Chapter: ____________________________________________________________________________________________________________________________

Address: _______________________________________________________________ City: __________________________ State: _______________ Zip Code: ____________

Telephone: Home ( ) ____________________________________________________________ Business ( ) ___________________________________________

Parent/Guardian (NAME): ____________________________________________________________ Phone: H ( ) ___________________________ADDRESS: ________________________________________________________________________ B ( ) __________________________STATE: ________________________________________________________________________ ZIP __________________________________________(*Examination must not have been given more than 90 days prior to activity. Date (s) of activity is/are _______________________________________________)

Emergency Contact if parent/guardian not available:Name: ___________________________________________________ Address: ______________________________________________________

State: ___________________________________________________ Phone H ( ) ____________________ B ( ) _____________________Name: ___________________________________________________ Address: ______________________________________________________State: ___________________________________________________ Phone H ( ) ____________________ B ( ) _____________________

Family Doctor: Name ___________________________________________________ Phone ( ) ______________________________________________ADDRESS: __________________________________________________________ STATE ___________________ ZIP ___________________________Medical Insurance Policy Name ____________________________________________ Policy # ___________________________________________________

To be answered by parent or guardian (Circle onelDOES YOUR CHID HAVE OR EVER HAD:I. Sickle Cell Anemia? NO YES2. Food medication allergy? NO YES3. Epilepsy, seizures, fainting spells? NO YES4. Heat Stroke or heat exhaustion? NO YES5. Diabetes mellitus (sugar)? NO YES6. Hemophilia (bleeding disorder? NO YES7. Bone or joint problem? NO YES8. Heart Problem? NO YES9. Hearing or vision problems? NO YES10. Eye glasses, contact lenses? NO YESII. Dentures or hearing aid? NO YES12. Loses of function of a body part? NO YES13. Require a special diet? NO YES14. Special psychiatric needs? NO YES15. High blood pressure, hypertension9 NO YESIf the answer to any of the above questions is “yes”, explain fully below. Give details as in whets the event occurred, your child’s current status., and anyspecial needs that he now has.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Medications:

1.

2.

3.

NAME EXACT DOSAGE SPECIFIC TIME GIVEN

Allergies. List:

Tetanus Booster. Date;

PARTICIPATION RELEASE (If applicant is under 21 years old)I hereby give my permission for (child’s name) __________________________________ to participate in the Omega Psi Phi Fraternity. Inc activities and events. I also grant to theOmega Psi Fraternity, Inc. permission to record my child/ward’s likeness and or voice for use by television, films, radio or printed media to further the aims of the Omega Psi PhiFraternity, Inc. in related campaigns, magazines articles. booklets, posters, and in other was it sees fit. I hereby release Omega Psi Fraternity, Inc., its insurer, agents,heirs, successors and assigns from any and all liabilities and claims in connections herewith.

CONSENT TO TREAMENT/EVIDENCE OF INSURANCEIn the event that my child should for any reason require any minor or surgical treatment and/or medication during the course of his attendance at orparticipation in the Omega Psi Phi Fraternity, Inc. activities. I authorize such physician or emergency care staff that Omega Psi Phi Fraternity. Inc. may appoint ordesignate to carry out the necessary treatment, or to take my child to the emergency room of any hospital, and further authorized the hospital and its medical staff to provide thetreatment deemed necessary by them for the well being of my child. It is understood, however, that if hospitalization or treatment of a more serious nature is required I will becontacted, if at all possible, by telephone for permission.

I, the undersigned, am a parent or legal guardian of the above specified child. I have read and fully understand the provisions of the above releases and have explained them to saidminor. I further declare that all of the statements that I have made herein, are true to the best of nay knowledge, information and belief. I hereby agree on behalf of myself and mychild to hold harmless and release the Omega Psi Phi Fraternity, Inc.. the attending physician(s). hospital, their insurers, agents, heirs, successors and assigns from any and all liabilitiesand claims arising out of any treatment rendered to my child.

Parent or Legal Guardian Signature _____________________________________________ DATE: _______________________________


Page 21 of 23

FORM 9AAttachment IllRevised 03/06

OMEGA PSI PHI FRATERNITY, INCRELEASE OF LIABILITY FOR REIMBURSEMENT OF PROCESSING

FEEBY the Releaser(s)_________________________________________________ referred to as “I”,

TO: The Omega Psi Phi Fraternity, Inc., the___District of the Omega Psi Phi Fraternity, Inc.,and_____________Chapter, “an unincorporated association of the Omega Psi Phi Fraternity, Inc.:, their officers, members, agents,employees and/or assigns, referred to as “You”,

If more than one person signs this Release, “I” shall mean each person who signs this Release.

I. Release. I release and give up any and all claims and rights which I may have against you pertaining to my right to recover the portion of sumsdesignated as a “processing fee” which was remitted by me to You. This releases all claims, including those of which I am not aware andthose not mentioned in this Release, which pertain to my right to recover said processing fee.

IT IS EXPRESSLY UNDERSTOOD AND AGREED that I have attended an “Information Session”, which I understand tobe a segment of the Membership Selection Program of the Omega Psi Phi Fraternity, Inc., sponsored by and through the ______District of theOmega Psi Phi Fraternity, Inc., and that I have remitted the sum of $1,050.00 (G) or $845.00 (UG) as required by my attendance at theInformation Session.

IT IS EXPRESSLY UNDERSTOOD AND AGREED that remittance of the aforementioned sum is not apromise, guarantee, or made in consideration of membership into the Omega Psi Phi Fraternity, Inc., the _____District of the Omega Psi PhiFraternity, Inc., and br___________________Chapter of the Omega Psi Phi Fraternity, Inc. I fully understand that my admission to membershipinto the Fraternity shall be governed by the rules promulgated within the Membership Selection Program Handbook.

IT IS EXPRESSLY UNDERSSTOOD AND AGREED that I shall be entitle to a refund of all other sumsremitted by me at the “Information Session” except for the processing fee of $105.00 (G) or $84.50 (UG)

IT IS FURTHER EXPRESSLY UNDERSTOOD AND AGREED that the remittance of $945.00 (G) or$760.50 (UG), which is the remainder of the monies submitted by me after the deduction of the processing fee, by “You”is in full accord and satisfaction, and in compromise of all disputed claims and I understand that I ani not entitled to recover any further sumsfrom “You”.

IT IS FURTHER EXPRESSLY UNDERSTOOD AND AGREED that remittance of the sum of $945.00 (G)or $760.50 (UG), shall be made in accordance with the rules set forth by the Membership Selection Handbook of the Omega Psi PhiFraternity, Inc. or as designated by the Grand Basileus of the Omega Psi Phi Fraternity, Inc., or his designee.

2. Who is Bound. I am bound by this Release. Anyone who succeeds to my rights and responsibilities, such asmy heirs or the executor of my estate, is also bound, This Release is made for your benefit and all who succeed to our rights andresponsibilities, such as your heirs or the executor of your estate,

3. Governing Law. This agreement shall be deemed a contract entered into pursuant to the laws of the Districtof Columbia and shall in all respects be governed, construed, applied and enforced in accordance with the laws of the District ofColumbia.

4. Signatures. I understand and agree to the terms of this Release.

Witnessed or Attested By:

_______________________________ ___________________________________(Seal) (Candidate)

FORM 9AAttachment IG

Revised 03/06

OMEGA PSI PHI FRATERNITY, INCTRANSCRIPT

Please attach an official copy of transcript.


Page 23 of23

Documents

OMEGA PSI PHI FRATERNITY, INC. INTERNATIONAL …